2. To provide an ethical, moral and practical framework for decision-making during a public health emergency.

Transcription

1 November 2010 TABLE TOP EXERCISE PARTICIPANT GUIDE When Routine Critical Care Resources Are Not Available Time expectations for each session: SECTION ACTIVITY TIME I Introduction 5 minutes II Exercise Part 1 10 minutes Discussion 10 minutes III Guidelines Education 20 minutes IV Exercise Part 2 20 minutes Discussion 15 minutes V Evaluation 10 minutes TOTAL EXERCISE TIME 90 minutes Exercise Objectives 1. To guide the allocation of critical care resources during a public health emergency, such as an influenza pandemic, when demand for supplies and equipment necessary for ventilatory and circulatory support exceeds supply. 2. To provide an ethical, moral and practical framework for decision-making during a public health emergency. 3. To provide an opportunity for members of the hospital medical staff to discuss and exercise using the Multi-principled Critical Care Resource Allocation Score (MCCRAS) triage guidelines. 4. To provide feedback to the State of Wisconsin on mass casualty triage and/or crisis standards of care.

2 Exercise Scenario It is May 2012 and the CDC and WHO have identified a new influenza strain that has documented person to person transmission with all ages susceptible, high infectivity and virulence and with unknown projected mortality rate. 1. The State of Wisconsin Department of Military Affairs Emergency Management Agency has declared a Public Health Emergency due to the number current and projected in hospital patients. 2. Your hospital is experiencing unavailability of critical resources and cannot access these resources from other sources. Ventilator and IV fluids are limited your supplier of IV fluids is unable to make delivery this week. 3. The hospital is unable to refer patients to another facility because other facilities cannot receive the referred patients. 4. The hospital internal emergency operations plan has been activated. You have been assigned by your hospital to place in rank order the next patients who arrive in the Emergency Department. Your ranking will be used by your hospital incident command to determine who will receive critical care resources and who will be assigned to supportive care.

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12 Clinical Management Decision Process for the Individual Patient ACTION ADDITIONAL INFORMATION Perform appropriate medical screening exam Provide initial treatment and stabilization Determine need for critical care resources (ventilatory and/or circulatory support) Evaluate for critical care resource eligibility Determine Sequential Organ Failure Assessment (SOFA) Score Calculate Multi-principled Critical Care Resource Allocation Score (MCCRAS) Provide MCCRAS to the hospital EOC for determination of allocation of critical care resources Criteria for Ventilatory Support Respiratory Failure - Refractory hypoxemia (SpO 2 less than 90% on non-rebreather mask or FIO 2 greater than 0.85), respiratory acidosis (ph less than 7.2), clinical evidence of impending respiratory failure, inability to protect or maintain airway. Hypoxia - ABG PO 2 less than or equal to 55 mm Hg or SpO 2 is less than or equal to 88%, awake and at rest on room air. Criteria for Circulatory Support Shock - Systolic blood pressure less than 90 mm Hg or relative hypotension with clinical evidence of shock (altered level of consciousness, decreased urine output or other evidence of end organ failure) refractory to volume resuscitation requiring vasopressor or inotrope support that cannot be managed in ward setting. Volume Depletion - Evidenced by orthostatic hypotension, commonly defined as a reduction in systolic blood pressure of 20 mmhg or greater, or a reduction in diastolic blood pressure of 10 mmhg or greater, within 3 min of undergoing orthostatic stress not resolved with 40 ml/kg of an isotonic intravenous solution and unable to take adequate fluids by mouth. Defer patient from receiving critical care resources if he/she has any of the following: a. Baseline severe and irreversible chronic neurological condition with and without persistent coma or vegetative state (physician judgment) b. Acute severe neurologic event with minimal chance of functional neurologic recovery, such as traumatic brain injury, severe hemorrhagic stroke, hypoxic ischemic brain injury, and intracranial hemorrhage (physician judgment) c. Severe acute trauma with a Revised Trauma Score of less than 2 (anticipated mortality of greater than 50%) d. Burns with a predicted hospital mortality of greater than 50% based on the FLAMES score or comparable scoring system Independent of the initial value, an increase in the SOFA score during the first 48 hours of ICU admission predicts a mortality rate of at least 50%. When determining rank order, scores should be ordered lowest to highest with resource allocation beginning with the lowest score. All patients to be assessed for eligibility and rescored after 48 hours

13 PRINCIPLE Multi-principled Critical Care Resource Allocation Score (MCCRAS) RATIONALE POTENTIAL SCORE ROW SCORE Save the most lives Best prognosis for short term survival SOFA score SOFA 5 or less SOFA 6-9 SOFA SOFA SOFA SOFA Opportunity to live through phases of life Priority to those who have not lived through life s stages Age in years *Age 0-12 Age Age Age Age Age 81 or greater Maximizing most lifeyears Best prognosis for long-term survival Comorbidities No comorbid conditions Likely limited impact on long-term survival Likely moderate impact on long-term survival Likely significant impact on long-term survival Likely profound impact on long-term survival Likely death within 1 year Comorbidities that may impact long term survival include: TOTAL SCORE Minimum total score = 0 Maximum total score = Known severe dementia medically treated and requiring assistance with activities of daily living 2. Advanced untreatable neuromuscular disease (such as ALS, end-stage MS, or SMA) requiring assistance with activities of d living or requiring chronic ventilatory support 3. Incurable metastatic malignant disease 4. Individuals whose weight exceeds 3 times their ideal body weight (BMI > 60 kg/m 2 ) 5. Second and third trimester pregnancy 6. New York Heart Association (NYHA) Functional Classification System for Congestive Heart Failure Class III or IV (moderate severe) 7. End stage liver disease with a PUGH SCORE >7 8. End stage pulmonary disease meeting the following criteria: a. Chronic Obstructive Pulmonary Disease (COPD) with Forced Expiratory Volume in one second (FEV1) < 25% predicted baseline, Pa02 <55 mm Hg, or severe secondary pulmonary hypertension b. Cystic fibrosis with post-bronchodilator FEV1 <30% or baseline Pa02 <55 mm Hg c. Pulmonary fibrosis with VC or TLC < 60% predicted, baseline Pa02 <55 mm Hg, or severe secondary pulmonary hypertension d. Primary pulmonary hypertension with NYHA class III or IV heart failure (g), right atrial pressure >10 mm Hg, or mean pulmonary arterial pressure >50 mm Hg 9. End stage renal disease with a glomerular filtration rate of less than 60 ml/min/1.73m 2 [CKD3 (Moderate)] for 3 months. 10. DNR orders with consideration of underlying disease process.

14 MCCRAS Post Exercise Survey Do not put your name on this survey; this is an anonymous survey of your perspective on today s table top exercise experience. Please read each question carefully. What is today s date? 1. Approximately how many years have you been a licensed health care provider? # 2. Prior to today, have you participated in a hospital emergency situation exercise where the patient needs for critical care resources exceeds supply? Yes No 3. Prior to today, have you participated in an actual hospital emergency situation where the patient needs for critical care resources exceeds supply? Yes No 4. Prior to today, have you ever heard of the Multi-principled Critical Care Resource Allocation Score (MCCRAS)? Yes No Based on your experience of today s disaster mass casualty triage exercise answer the following questions. 5. PRIOR TO this exercise, how confident do you feel in using the MCCRAS during when routine critical care resources are not available? Very confident Confident Somewhat Confident Not Confident 6. NOW that the exercise is completed, how confident do you feel in using the MCCRAS when routine critical care resources are not available? 7. PRIOR TO this exercise, I felt that: Very confident Confident Somewhat Confident Not Confident the MCCRAS approach is easier to use than my current disaster triage protocol the MCCRAS approach is similar to my current disaster triage protocol the MCCRAS approach is more difficult to use than my current disaster triage protocol 8. NOW that the exercise is completed, I feel that: the MCCRAS approach is easier to use than my current disaster triage protocol the MCCRAS approach is similar to my current disaster triage protocol the MCCRAS approach is more difficult to use than my current disaster triage protocol

15 MCCRAS Exercise After Action Feedback Today s Date: 1. The Hospital Resources Management Guidelines Operational Framework is useful Strongly Disagree Strongly agree The Multi-Principled Critical Care Resource Allocation Score (MCCRAS) approach is impartial 3. The ineligibility requirements to defer patients from receiving critical care resources are just Strongly Disagree Strongly agree Strongly Disagree Strongly agree The method of determining comorbidity is rational Strongly Disagree Strongly agree The MCCRAS is easy to calculate 6. The MCCRAS is non-discriminatory towards all types of patients such as pediatric and special needs populations 7. Would you recommend statewide adoption of these Clinical Management Guidelines for Health Care Providers When Routine Critical Care Resources Are Not Available? Strongly Disagree Strongly agree Strongly Disagree Strongly agree Yes No Any additional comments?